Cardio presentations Flashcards
A 50-year-old man presents with a complaint of central chest discomfort of 2 weeks’ duration, occurring after walking for more than 5 minutes or climbing more than one flight of stairs. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years. On examination, his blood pressure is 144/92 mmHg with a heart rate of 82 bpm. The remainder of his examination is normal.
Stable angina
A 60-year-old man with a history of a myocardial infarction presents for follow-up. He was started on aspirin, beta-blocker, and statin therapy after his heart attack. In the past 2 weeks the patient has noted return of chest pressure when he walks rapidly. The chest pressure resolves with sublingual glyceryl trinitrate or a decrease in his activity level. He is a former smoker and has modified his diet and activity to achieve his goal body weight. He is normotensive on examination with a heart rate of 72 bpm. The remainder of his examination is normal.
Stable angina
A 65-year-old man, who smokes and has a history of hypertension and peripheral vascular disease, now presents with increasing frequency and severity of chest discomfort over the past week. He reports that he previously had chest pain after walking 100 metres, but now is unable to walk more than 50 metres without developing symptoms. The pain radiates from his chest to the left side of the neck and is only eased after increasing periods of rest.
Unstable angina
A 69-year-old man develops worsening substernal chest pressure after shovelling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for hypertension and he has been told by his doctor that he has borderline diabetes. On examination in the accident and emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and blood pressure is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads.
NSTEMI
A 54-year-old man with a medical history of hypertension, diabetes, dyslipidaemia, smoking, and family history of premature coronary artery disease presents with retrosternal crushing chest pain (10/10 in intensity), radiating down the left arm and left side of the neck. He feels nauseated and light-headed and is short of breath. Examination reveals hypotension, diaphoresis, and considerable discomfort with diffuse bilateral crackles on chest auscultation. ECG reveals convex ST-segment elevation in leads V1 to V6.
STEMI - Acute myocardial infarction
A 70-year-old woman describes increasing exertional dyspnoea for the last 2 days and now has dyspnoea at rest. She has a history of hypertension for the last 5 years and a 35 pack-year smoking history, but no other established illnesses. Current medications are a diuretic daily for the last 3 years. She has been prescribed an ACE inhibitor but failed to collect the prescription. On examination her BP is 190/90 mmHg, and her heart rate is 104 bpm. There is an audible S4 and the jugular venous pressure is elevated 2 cm above normal. Lung examination reveals fine bibasal crepitations. Echocardiogram demonstrates normal biventricular size, a left ventricular ejection fraction of 60%, and no significant valvular disease.
Heart failure (Acute)
(preserved ejection fraction)
A 73-year-old woman with a history of myocardial infarction presents to the accident and emergency department. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure is elevated 5 cm above normal, there is a gallop rhythm, and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination. Echocardiogram shows an ejection fraction of 35%
(acute) heart failure
(reduced ejection fraction)
A 67-year-old woman presents to her primary care physician complaining of increasing shortness of breath, especially when trying to sleep. She has a history of poorly controlled hypertension and hyperlipidaemia, and is being treated with a beta-blocker and statin therapy. She does not smoke and she drinks alcohol in moderation. On examination, her blood pressure is 160/90 mmHg and heart rate is 126 beats per minute. There is an audible S4 and the jugular venous pressure is elevated 3 cm above normal. There is no oedema, but she has fine bilateral mid to lower zone crepitation on lung examination. The ECG shows left ventricular hypertrophy, and a transthoracic echocardiogram shows left ventricular hypertrophy, left atrial dilation, and normal right ventricular systolic function, with a left ventricular ejection fraction of 40% and elevated B-type natriuretic peptide (BNP).
Heart failure
A 60-year-old man presents to the accident and emergency department. He reports being progressively short of breath. He has a history of hypertension, non-insulin-dependent diabetes mellitus, and has been a heavy smoker for more than 40 years. He underwent a successful primary angioplasty for a large acute anterior myocardial infarction 2 months ago. His blood pressure is 120/75 mmHg, his heart rate 110 beats per minute, and his respiratory rate 30. He has elevated neck veins and a prominent S3. His ECG shows sinus tachycardia, and a transthoracic echocardiogram performed in the accident and emergency department reveals impaired left ventricular systolic function, with an ejection fraction of 20%.
Heart failure
A 55-year-old man with a history of hypertension (well controlled with medication) and cigarette smoking presents to his general practitioner with a 2-day history of constant and gnawing epigastric pain. The pain has been steadily worsening in intensity. He says the pain radiates to his lower back and both groins at times. There is a palpable pulsatile mass just left of midline above the umbilicus. He is immediately referred to a regional vascular service for definitive management, but during transfer becomes hypotensive and unresponsive.
Abdominal aortic aneurysm
A 59-year-old man presents to the accident and emergency department with a sudden onset of excruciating chest pain, which he describes as ‘stabbing’. He has a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.
Aortic dissection
A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidaemia presents to the accident and emergency department with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest. His symptoms came on suddenly 4 hours ago. Physical examination shows an irregularly irregular radial pulse rate at 90 to 110 bpm, a BP of 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination.
Atrial fibrillation
A 42-year-old man complains of palpitations followed by dizziness and brief loss of consciousness. His wife reports that he is pale and short of breath. Emergency medical services were called and found him pulseless. The ECG revealed a rapid, irregular wide complex tachycardia. Later he was successfully resuscitated with two successive direct-current shocks.
Wolff parkinson white syndrome - AVRT
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A 35-year-old man presents to an accident and emergency department with palpitations, shortness of breath, dizziness, and chest pain of 4 hours’ duration. An ECG demonstrated narrow-complex short RP tachycardia that responded to intravenous adenosine. The ECG during sinus rhythm revealed ventricular pre-excitation.
AVRT - wolff parkinson white syndrome
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A 65-year-old woman presents with unilateral leg pain and swelling of 5 days’ duration. She has a history of hypertension, congestive heart failure, and recent hospitalisation for a total knee replacement. She had been recuperating at home but on beginning to walk, her right leg became painful, tender, and swollen. On examination there is pitting oedema on the right and the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity.
Deep vein thrombosis
